Evaluation and management: bill the correct level of care

The evaluation and management (e/m) patient visit is the foundation of most physician practices, but many practitioners are uncertain how to choose the correct Current Procedural Terminology (CPT) code for an e/m visit, thereby losing revenue.

The underlying problem is two-fold, according to coding experts. First is not understanding how the coding system for e/m visits (CPT codes 99201 through 99205 for new patients, and 99211 through 99215 for returning patients) works. Second is in- adequately documenting to support their choice of code.

When uncertain what code to use, many physicians’ instinct is to avoid risk by downcoding. When the American Academy of Professional Coders (AAPC) conducted a review of 60,000 physician billing audits in 2012, they found that more than a third of the records were either undercoded or under documented. That represented an average of $64,000 in foregone or at-risk revenue per physician.

“Doctors think from a clinical perspective, which they should,” says Raemarie Jiminez, CPC, CPB, vice president of member and certification development for the AAPC. “They’re not thinking about documenting the record to support the codes. That’s where coders come in, to say ‘I know all this is going on in your head, but we need you to properly describe it so that you qualify for the level of service you provided.’”

Complexity level is key to coding

As explained in the Medicare Learning Network’s 2010 “Evaluation and Management Services Guide,” the correct code for an e/m visit generally is tied to the complexity of the visit, which in turn is determined by the number of problems and the extent to which they are addressed.

Three components determine the appropriate billing level for an e/m visit: history, examination, and medical decision-making. Each of these, in turn, has various levels of complexity and sub-components. For example, a history can be “problem-focused,” “expanded problem-focused,” “detailed,” or “comprehensive.” The proper level of complexity is determined by the presence or absence of documentation for four sub-elements: chief complaint, history of present illness, review of systems, and past, family, and/or social history.

The complexity levels for an examination are the same as those for history, while the complexity levels for medical decision-making are “straightforward,” “low complexity,” “moderate complexity,” and “high complexity.”

Among the three components, medical decision-making represents the biggest challenge in terms of documentation and interpretation, says Jeannie Z. Engel, MD, FACP, associate professor at the University of Utah School of Medicine and a frequent lecturer on coding for the American College of Physicians. “History and exam lend themselves to check boxes and objective quantification, whereas medical decision-making cannot be so easily quantified,” Engel says.

Documentation is crucial

The key to supporting medical decision-making choices—as well as most other aspects of coding—is to thoroughly document what was done for the patient and why. Engel recommends approaching documentation in a “problem-based” way.

“Document the medical issues you are dealing with during the visit,” she says. “Not only is it good patient care, but it also facilitates an external coder or auditor being able to pick out the number of diagnoses you’re dealing with, which is a major part of medical decision-making.”

Common examples of not fully documenting decision-making, she adds, are doctors neglecting to note explicitly that they’ve personally reviewed imaging, and obtained historical information about a patient from someone other than the patient, such as a family member or caregiver. “All these are things we often do as physicians, but if you don’t include having done it you don’t get credit for it,” she says.

Another common error is confusing familiarity with the patient with complexity of decision-making, says Nancy Enos,
FACMPE, CMPA, principal of Enos Medical Coding in Warwick, Rhode Island. “The medical decision-making might be at a level to support a 99214 because the patient has multiple problems and the doctor is looking at lab results and they have a medical history to support it, they still have a tendency to bill it as a 99213 because the patient is familiar to them and is doing well, and they don’t want to get into trouble,” Enos says.

Enos adds that the 99213 level should be used for “a healthy patient with an uncomplicated illness like a virus or sinusitis, not one with something like hypertension or A-fib. That’s much more complicated,” she says.

EHRs can lead to upcoding

The widespread use of electronic health record (EHR) systems has in some ways contributed to physicians’ coding problems by prompting doctors to document at a level beyond what the encounter really requires—upcoding—says Boyd R. Buser, D.O., FACOFP, a member of the CPT editorial panel.

“Now you start getting beyond the question of whether you’ve documented the service properly to whether the service you’ve documented was medically necessary. And that’s where a lot of physicians start getting into trouble,” he says.

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